TURNING RESOURCES INTO...

M A L A R I A C O N T R O L

I N T H E W H O

A F R I C A N R E G I O N

A N N U A L R E P O R T 2 0 0 3

M A L A R I A U N I TD I V I S I O N O F P R E V E N T I O N A N D C O N T R O L O F C O M M U N I C A B L E D I S E A S E S

R E G I O N A L O F F I C E F O R A F R I C A • W O R L D H E A LT H O R G A N I Z AT I O N

TURNING RESOURCES

I N T O R E S U LT S

M A L A R I A C O N T R O L

I N T H E W H O

A F R I C A N R E G I O N

TURNING RESOURCES

INTO RESULTS

A N N U A L R E P O R T 2 0 0 3

M A L A R I A U N I TDIVIS ION OF PREVENTION AND CONTROL OF COMMUNICABLE DISEASES

REGIONAL OFFICE FOR AFRICA • WORLD HEALTH ORGANIZATION

© World Health Organization, 2004

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Photographs: World Health Organization

Design and Print: SP Litho (Pvt.) Ltd.

iii

MALAR IA UN IT • D IV IS ION OF PREVENT ION AND CONTROL OF COMMUNICABLE D ISEASES

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Acronyms and Brand Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Preventive Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Promoting Access to Effective Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Community-Based Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Epidemics Preparedness and Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Capacity Development and Support to National Health Systems . . . . . . . . . . . . . . . 22

Monitoring and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Operational Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Economics of Malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Partnerships Development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Program Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Issues Associated with Implementation of the 2003 Work Plans. . . . . . . . . . . . . . . . 41

West and Central Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

East and Great Lakes and Southern Africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Regional Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Contents

M A L A R I A C O N T R O L I N T H E A F R I C A N R E G I O N • T U R N I N G R E S O U R C E S I N T O R E S U LT S

iv

Figures

Figure 1: The malaria algorithms are an easy-to-use tool for case

management using the IMCI approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Figure 2: Current treatment policies for uncomplicated malaria in the

African Region (31 Dec 2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Figure 3: Sub-regional technical support networks for monitoring

antimalarial treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Figure 4: Availability of 1st and 2nd line antimalarial drugs in various

health facilities of Debub and Gash Barka zones of Eritrea,

November 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Figure 5: Percentage of suspected malaria cases that received CQ+SP

on the day of the survey in Debub and Gash Barka health

facilities, November 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Figure 6: Global Fund support to fight malaria in the African Region . . . . . . . . 25

Figure 7: Status of malaria-related databases at country level as of

December 2003. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Figure 8: Sample menus of the composite database in Access 2002. . . . . . 29

Figure 9: AFRO malaria epidemiological blocs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Tables

Table 1: Availability and use of ITNs in selected districts of The Gambia

(2002) before and after implementation of NICs . . . . . . . . . . . . . . . . . . . . 3

Table 2: Status of the promotion and/or the implementation of the IPTp

policy in 2003. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Table 3: Studies on antimalarial efficacy tests involving ACTs in Burundi . . 10

Table 4: Levels of appropriateness of fever treatment in selected

districts in Uganda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Table 5: Areas of coordination/collaboration with other programs. . . . . . . . . . . 40

List of Figures and Tables

v


Children are the flowers of our fight, the main reason for our struggle

and the future of our people. AMÍLCAR CABRAL

Malaria is still a complex public health problem in sub-Saharan Africa, causing 300 millionto 500 million episodes of acute illness per year. While the disease affects the lives ofnearly everyone across the continent, children under the age of five years and pregnantwomen are the most vulnerable groups. Furthermore, the disease contributes to theentrapment of disadvantaged communities in a vicious cycle of poverty.

The most daunting challenge faced by national malaria control programs over the pastthree decades is the significant increase in parasite resistance to commonly used, safeand affordable antimalarial drugs. This poses a serious threat to effective efforts toachieve significant malaria-related mortality and morbidity reduction. Efforts to makeeffective drugs more available and more affordable to at-risk groups are hampered bythe limited availability and the high costs of the drugs. Coverage of at-risk groups withpreventive interventions such as insecticide treated nets (ITNs) and intermittentpreventive treatment (IPTp) for pregnant women is still very low.

However, a favorable environment for funding malaria control activities now exists. There is a unique opportunity for governments of endemic countries and their nationaland international partners to increase programmatic coverage of cost-effectiveinterventions to control malaria in the African Region.

During 2003, and in line with the Regional Strategy for malaria control, the RegionalOffice strengthened, in various ways, the existing capacity of malaria prevention andcontrol programs in several countries. The aim of this Annual Report is to shareinformation with countries and partners on progress made at country level towardsmalaria control. It spreads a message of hope and confidence on the strengths ofAfrica to significantly slow down the current trend of malaria morbidity and mortality inthe Region.

Provision of technical support to countries for the adoption of appropriate antimalarialdrug policies received priority as did development of strategies for increasing access to malaria control interventions at all levels of national health systems, particularly atcommunity level. Also among the priorities were epidemic detection and response,capacity development for planning, management, implementation, monitoring andevaluation, operational research, partnership development and resource mobilization,advocacy and communication for behavioural changes.

We strongly believe that broad partnerships involving all interested stakeholders andfocused action will turn available resources into results. We also believe that malariacan be controlled in the African Region.

Dr Magda Robalo Correia e SilvaMalaria Regional AdvisorDivision of Prevention and Control of Communicable Diseases

Foreword

Acknowledgements

The achievements highlighted in this report would not have been possible without the

support of all our partners, whose financial contribution was turned into results as

described in the various sections of the report. We wish to thank DFID, USAID, CIDA,

and the World Bank for having remained the major financial partners of the Unit.

We are also grateful for the various forms of support that were provided by MoHs,

WRs, and NMCP management and technical teams. Our gratitude also goes to ICP

team leaders and staff and NPOs/IPOs for the wonderful technical work they do

everyday in the subregions and countries where they are stationed.

Finally, we wish to thank all the members of professional and general service staffs

of the Division of Prevention and Control of Communicable Diseases and other

Departments in AFRO for their hard work and dedication, and for their commitment to

malaria control in the African Region.

vii


ACT Artemisinin-based Combination Therapy

AFRO Regional Office for Africa/World Health Organization

AIDS Acquired Immune Deficiency Syndrome

ANC Antenatal Care

AQ Amodiaquine

ASU Artesunate

CBIs Community-Based Interventions

CIDA Canadian International Development Agency

CSR/IDSR Communicable Disease Surveillance and Response/

Integrated Disease Surveillance and Response

DFID Department for International Development

DHS Demographic and Health Survey

EPR Epidemic Preparedness and Response

EPI Expanded Program on Immunization

GFATM Global Fund to fight AIDS, TB and Malaria

GMP Gates Malaria Partnership

HIV Human Immunodeficiency Virus

HMIS Health Management Information System

HMM Home Management of Malaria

HOMAPAK Brand name of a pre-packaged antimalarial drug

HQ World Health Organization Headquarters

ICIPE International Center for Insect Physiology and Ecology

ICP Intercountry Programs

IDSR Integrated Disease Surveillance and Response

IEC Information, Education and Communication

IMCI Integrated Management of Childhood Illness

IPO International Program Officer

IPR Intellectual Property Right

IPTp Intermittent Preventive Treatment

IRS Indoor Residual Spraying

ITN Insecticide Treated Net (Bed Net)

Acronyms and Brand Names


viii

KidCare Brand name of an antimalarial drug approved by the Federal MoH

of Nigeria

IVM Integrated Vector Management

MAL-AFRO Malaria Unit at the Regional Office for Africa

MDGs United Nations Millennium Development Goals

M&E Monitoring and Evaluation

MIPESA Malaria in Pregnancy Coalition for East and Southern Africa

MoH Ministry of Health

MPS Making Pregnancy Safer Program

NGO Non-Governmental Organization

NIC Mosquito Net Impregnation Campaign

NMCP National Malaria Control Program

NPO National Program Officer

PaluStop Brand name of an antimalarial drug approved by the MoH of

Madagascar

POA Plan of Action

PSI Population Services International

RAOPAG Réseau d’Afrique de l’Ouest Africain pour la Prévention et la Lutte

contre le Paludisme pendant la Grossesse

RBM Roll Back Malaria

REAPING Roll Back Malaria Essential Actions, Products, Investments and Gaps

SP Sulphadoxine-Pyrimethamine

SWAPs Sector Wide Approaches

TB Tuberculosis

TBAs Traditional Birth Attendants

THPs Traditional Health Practitioners

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

WRs WHO Representatives

WCO World Health Organization Country Office

WHO World Health Organization

WHO/AFRO Regional Office for Africa of the World Health Organization

ix


During 2003, the Malaria Control Unit of WHO/AFRO set priorities that included the

provision of technical support to countries for adoption of appropriate antimalarial drug

policies and the development of strategies for increasing the coverage of malaria

control interventions at all levels of the health system, particularly at the community

level. Priorities also included strengthening epidemic detection and response, program

management, monitoring and evaluation systems, operational research, partnership

building, advocacy and resource mobilization.

In collaboration with the Vector Biology and Control Unit, the Malaria Unit supported

seven countries in preparing national action plans for scaling up insecticide treated nets

(ITN) interventions. In the selected districts of these countries, utilization of insecticide

treated nets increased from around 5% to more than 90%. The proportion of children

under-five years of age and pregnant women sleeping under ITNs increased from

around 10% to more than 80%. In addition, countries in southern Africa (Angola,

Zambia and Zimbabwe) received support in planning, organization and timely

implementation of indoor residual spraying (IRS) of insecticides for malaria control.

At present, intermittent preventive treatment (IPTp) in two doses of sulphadoxine-

pyrimethamine (SP) has been shown to reduce significantly the prevalence of anemia

and placental malaria infections during pregnancy. In 2003, the Unit supported several

countries (DRC, Gabon, Mozambique, São Tomé and Príncipe, and Senegal) to adopt

and/or implement IPTp. Five countries (Cameroon, Ghana, Madagascar, Nigeria, and

Sierra Leone) were supported to build national consensus on IPTp strategy. The Unit

also supported establishment of a Malaria in Pregnancy Network in West Africa and

the functioning of the East and Southern Africa Coalition (RAOPAG and MIPESA,

respectively).

The year also witnessed three countries implementing artemisinin-based combination

therapy for treatment of malaria. Burundi and the island of Zanzibar implemented

amodiaquine plus artesunate treatment policy, and Zambia phased in artemether-

lumefantrine treatment in seven districts. During the past 12 months, with the support

of the Regional Office, four countries (Mozambique, Gabon, São Tomé and Príncipe,

and Senegal) adopted combination treatment for uncomplicated malaria.

In the area of case management, 14 countries were supported to improve capacity

of health workers for malaria case management and supervision. Three of these

countries also adapted new treatment guidelines. In five countries, algorithms for

case management were field tested.

Factors that constrain efforts to scale up prompt access to appropriate malaria

treatment include limited availability and affordability of efficacious drugs (e.g.,

artemisinin-based combination therapy - ACTs) and the lack of a tool to estimate

Executive Summary


x

accurately drug needs for malaria treatment. The focus for 2004 will be to support

countries to accelerate decision-making processes for treatment policy review, to

develop tools for estimating and forecasting needs for ACTs at country level, and to

explore possibilities for establishing a global drug facility for ACTs.

Community-based interventions (CBIs) are crucial for attaining the Abuja targets by

increasing coverage of prompt and effective treatment and the use of ITNs. In

collaboration with the Integrated Management of Childhood Illness (IMCI) strategy,

various countries received technical support to complete development of strategic and

operational plans for scaling up CBIs. An assessment of the impact of CBIs in various

countries has shown that greater community participation in malaria control activities

translates into more households using ITNs and lower malaria-related morbidity and

mortality.

Scaling up home management of malaria (HMM) in 2003 was confined to a few project

areas. Its focus has been to empower mothers and caretakers with knowledge and

skills about malaria management and, where feasible, to make prepackaged drugs

available to communities. Statistical evidence shows that the districts implementing

HMM achieved high levels of appropriate treatment of fever.

Greater commitment of countries for implementation of CBIs, a good working

relationship with national program officers (NPOs), the support of other partners such

as UNICEF and the collaboration with other programs such as IMCI, CSR/IDSR,

Reproductive Health, Health Promotion and Education are major facilitating factors.

However, limited availability of antimalarial commodities (e.g., ITNs, insecticides,

efficacious antimalarial drugs) within communities, limited capacity building for

stronger advocacy and IEC for behavior change, and weak drug regulatory and drug

management structures for assuring drug quality and management at all levels are

serious challenges to scaling up HMM.

The focus of the fourth Joint Malaria and IMCI Task Forces Meeting held 23-25

September 2003 in Harare, Zimbabwe, was on community-based actions for

prevention and control of childhood morbidity and mortality. Countries and partners

shared experiences on how to scale up community-based interventions and reinforced

their partnerships with emphasis on advocacy and resource mobilization efforts.

Concrete recommendations on how countries can progress towards achieving the

Abuja targets and the Millennium Development Goals were also made.

Roll Back Malaria (RBM) has been supporting efforts to improve the recognition and

response to malaria epidemics. Guidelines for setting up an epidemic management

committee and a rapid response team at national and district levels for epidemic control

have been elaborated. Fifteen epidemic-prone countries developed a preparedness

plan for timely detection of epidemics and timely response. The Regional Office carried

out many activities to support countries facing major malaria epidemics (Burundi,

Ethiopia, Madagascar, Mauritania, and Senegal).

xi


To meet countries’ increasing demands and needs, the Gates Malaria Partnership

(GMP) seconded a capacity development coordinator to the Malaria Unit to help take

forward the strategic plan for capacity development in the African Region.

During the year under review, 81 malaria program managers and health workers from

34 countries were trained in courses in Ethiopia, Benin and Mozambique on Malaria

and Planning Its Control. Furthermore, 14 senior laboratory health professionals from

Anglophone countries were trained in Ndola, Zambia, to cascade capacity for

laboratory health workers at district level.

By the end of 2003, 35 of 43 malarious countries had completed their strategic plans

and had begun scaling up implementation of malaria control activities. Considerable

staff time and financial resources were committed in supporting countries to develop

and submit fundable proposals to the Global Fund to fight AIDS, TB and Malaria

(GFATM). During rounds one to three, 33 countries had their malaria proposals

approved for funding. GFATM committed more than US$300 million to national

malaria programs for two years.

Factors contributing to the development of health systems throughout the African

Region include increased political, policy and program support from governments and

partners and increased investments and interest from the international community in

diseases of poverty. Some of the factors constraining the work of AFRO include limited

financial and human resources, delays by national authorities in clearing missions,

limited availability of consultants to undertake missions, and mismatch between the

time the national authorities are ready to receive the mission and the time consultants

are available to undertake the missions.

The Malaria Unit has strengthened monitoring and evaluation systems in many malaria-

endemic African countries. Capacity for monitoring and evaluating the implementation of

malaria control activities was strengthened in 14 countries by establishing composite

databases and by training in data management more than 100 health workers and data

managers/clerks from the NMCP, IDSR, HMIS, IMCI, EPI, the university and research

institutes. The first edition of the Malaria Country Profiles, intended to be a useful tool

in policy and decision-making, was published in 2003.

At country level, limited human resources are a major constraint to develop and sustain

effective malaria-related monitoring and evaluation systems. However, with the growing

interest of partners in malaria monitoring and evaluation and the new window of

opportunity created by the GFATM initiative, an anticipated increase for monitoring

and evaluation activities will facilitate the harmonization and integrated approach

within countries.

The Malaria Unit, in collaboration with WHO-HQ, supported the Mozambique Ministry of

Health in evaluating the effectiveness of selected traditional herbs or plants in malaria

treatment and prevention efforts. In Uganda, the Malaria Unit and CIDA supported the


xii

Ministry of Health in community resource mobilization to increase the access of

pregnant women to IPTp.

Results from studies undertaken with the support from the Unit have confirmed that

the rate at which malaria impedes economic growth in the African Region ranges from

0.41% in Ghana to as high as 3.8% in Nigeria and 8.9% in Chad, based on preliminary

results. The burden of malaria treatment is particularly enormous for the poorest

households. In Ghana, for example, the direct cost to the household of treating

malaria is US$6.87 for each episode of malaria. Although this amount is well beyond

the capacity of most households in Ghana, when the indirect costs are computed,

the cost of malaria treatment comes to an even higher figure of US$8.92.

During the period under review, the Malaria Unit worked closely with its traditional

partners and embraced new partners in the fight against malaria. As a key partner in

the Global RBM Partnership, and the base for the Partnership Secretariat in the Region,

the Unit hosted the third RBM board meeting in Harare in September and, in February,

it hosted a meeting of African representatives on the RBM Partnership Board with

members of their constituencies. The Unit facilitated African representatives to

represent the Region on the RBM board and countries to nominate RBM focal

people at country level for partnership development.

At the technical level, the Malaria Unit provided input into deliberations of RBM

Partnership on key developments during the year, such as meetings on access to

and financing of ACTs, the development of malaria-related monitoring and evaluation

systems, malaria in pregnancy, etc.

DFID, USAID, and the World Bank remained the principal financial partners of the Unit.

With funds from these partners, the Malaria Unit was able to strengthen its human

capacity at regional, intercountry and country levels, and extend its technical support in

quality and quantity to countries of the Region. The Malaria Unit, working with its Malaria

Action Coalition (MAC) partners, provided technical support to several countries during

the year, particularly in the areas of drug policy change and malaria prevention and

control during pregnancy.

The current staffing levels of the Malaria Unit represent a strengthened capacity to meet

the malaria control needs of Member States. After the Country Office, intercountry

teams provide the second level of communication for procurement of technical and

managerial support in the context of country planning and management on a periodic

basis. National or international program officers (NPOs/IPOs) work specifically with the

Ministry of Health to focus on malaria control activities that include prioritizing, planning

and budgeting, especially at the district level and implementation of key activities at

community and household level. NPOs and IPOs provide day-to-day support that

ranges from technical to strategic and tactical.

AFRO is committed to ensure that Member States receive the highest quality of

required technical support to curb the malaria burden.

1


Malaria is still a complex public health problem for which there is no magic bullet, no

quick or easy solution, particularly in Africa, where approximately 80-85% of cases and

90% of deaths worldwide due to malaria occur. While the disease affects the lives of

nearly everyone across Africa south of the Sahara, children under the age of five years

and pregnant women are the most vulnerable groups. The economic loss due to

malaria in Africa is an estimated US$12 billion annually. Furthermore, the disease

contributes to the entrapment of disadvantaged communities in a vicious cycle

of poverty.

Over the past three decades, parasite resistance to commonly used, safe and

affordable antimalarial drugs has increased significantly. This poses a serious threat to

efforts to achieve significant malaria-related mortality and morbidity reduction. Despite

the concerted efforts of national authorities and partners, coverage of at-risk groups

with preventive interventions such as insecticide treated nets (ITNs) and intermittent

preventive treatment (IPTp) is still very low. Cost-effective tools for malaria control are

available but largely inaccessible to the needy, due to the weaknesses of the health

systems and the high costs of such interventions, among other factors.

However, there is now a favorable environment for funding malaria control activities, as

illustrated by various initiatives including the emergence and functioning of the Global

Fund to fight AIDS, TB and Malaria (GFATM). This initiative offers a unique opportunity

for governments of endemic countries and their national and international partners to

increase programmatic coverage of cost-effective interventions to control malaria

throughout the African Region.

During 2003, and in line with the regional strategy for malaria control, the Regional

Office strengthened the existing capacity of malaria prevention and control programs

in several countries in various ways. Providing technical support to countries for the

adoption of appropriate antimalarial drug policies received priority, as well as developing

strategies for increasing access to malaria control interventions at all levels of the health

system, particularly at the community level. Epidemic detection and response, capacity

strengthening for planning, management, implementation, monitoring and evaluation,

operational research, partnership building, advocacy and resource mobilization also

received special attention.

Introduction


2

Insecticide treated nets and IPTp are preventive measures being promoted to ensure that expectant mothers deliver healthy babies

The two core prevention strategies that must be implemented in all malaria-endemic

African countries are the use of insecticide treated nets (ITNs), which can cut malaria

transmission by more than half, and the protection of pregnant women by using both

ITNs and IPTp as part of routine antenatal care. IRS should also be promoted where

appropriate.

A comprehensive approach for the prevention and management of malaria during

pregnancy is based on a combination of IPTp, support for the use of ITNs and prompt

access to effective treatment for pregnant women ill with malaria. At present, the

standard IPTp regimen is a therapeutic dose of sulphadoxine-pyrimethamine (SP)

given at least twice during the second and third trimester. IPTp in two doses of SP

during pregnancy has been shown to reduce significantly the prevalence of anemia

and placental malaria infections at the time of delivery.

In 2003, priority in vector biology and control was given to strengthening technical

capacity in selected countries for: 1) research entomology to inform planning and

ensure evidence-based implementation of vector control activities, 2) scaling up the

use of ITNs and IRS; and 3) developing and implementing integrated vector

management (IVM). Throughout the year, efforts to strengthen vector control operations

Preventive Interventions

3


focused on supporting countries to expand their coverage of ITNs and ensuring

adequate preparations for indoor residual spraying.

Achievements

To assist countries plan and implement ITNs toward achieving the Abuja targets of 60%

of ITN coverage of high-risk groups by 2005, the Unit provided technical support to

seven countries preparing national action plans for scaling up ITN programs. In the

selected districts of these countries, the proportion of adequately treated mosquito nets

increased from around 5% to more than 90% and the proportion of children under five

years and pregnant women sleeping under ITNs increased from around 10% to more

than 80%. A regional database on the use of ITNs monitors the progress made in

distribution and use of ITNs and, ultimately, is used to evaluate the impact of ITNs

on disease burden. The illustrative example of The Gambia follows.

ITN Coverage in The Gambia NIC campaigns have translated into greater availability and use of ITNs

Mass mosquito nets impregnation campaigns (NICs) were initiated in 2001 to increase

the re-treatment of nets owned by communities. In 2001 and 2002, this strategy was

tested and documented in Cameroon, Eritrea, The Gambia and Mali. Table 1 shows the

availability and use of ITNs in The Gambia in 2002. These data suggest that NICs can

translate into greater levels of availability and use of ITNs.

Table 1: Availability and use of ITNs in selected districts of The Gambia (2002) beforeand after implementation of NICs

Niamina East

ITN indicators Before NICs After NICs

% of households with at least one mosquito net 99.5 99.8

% of households with at least one ITN 50.5 99.2

% of ITNs among the total number of nets 32.0 96.8

% of children under 5 sleeping under an ITN 22.6 98.6

% of pregnant women sleeping under an ITN 29.8 98.6

Source: VBC Unit, 2003


4

Southern African countries (Angola, Zambia and Zimbabwe) also received support in

planning, organizing and implementing indoor residual spraying (IRS) of insecticides for

malaria control. IRS was implemented timely and appropriately in these countries.

In the area of malaria prevention and

control during pregnancy, countries

were supported to adopt sound

policies based on IPTp and ITNs,

along with anemia prevention and

malaria case management.

The Malaria Unit provided support

to eight countries (Burkina Faso,

Democratic Republic of Congo,

Gabon, The Gambia, Mali,

Mozambique, São Tomé Príncipe,

and Senegal) to adopt and/or

implement IPTp in 2003. Five

other countries (Cameroon, Ghana,

Madagascar, Nigeria, and Sierra

Leone) were supported to build

national consensus about the IPTp

strategy. The Unit supported the establishment of Malaria in Pregnancy network in

West Africa (RAOPAG) and the functioning of the East and Southern Africa Coalition for

Malaria Prevention and Control during Pregnancy (MIPESA). Table 2 shows the level of

promotion and implementation of the IPTp policy.

The promotion of use of ITNs, particularly by at-risk groups,is one of the major strategies of Malaria Control

Table 2: Status of the promotion and/or the implementation of the IPTp policy in 2003

Building consensus Building consensusIPTp policy adopted IPTp policy adopted on the adoption of on the adoption of

and not yet and implemented IPTp policy (IPTp IPTp (IPTp testedimplemented at a small scale non implemented) in Pilot sites)

Senegal Democratic Ghana Burkina FasoGabon Republic Sierra Leone MaliSão Tomé and of Congo Nigeria

Príncipe MadagascarMozambique

5


Challenges

• To predict the magnitude and the profile of resistance to an antimalarial drug such

as SP;

• To better understand the adverse effects of malaria during pregnancy in low

transmission areas;

• To obtain collaboration between Reproductive Health and Malaria Control in efforts

to promote IPTp strategy;

• To make effective drugs more available and more affordable during pregnancy on a

sustainable basis;

• To increase the level of ITN coverage to protect at least 60% of children under five

and pregnant women by 2005 in as many countries as possible;

• To surmount cultural barriers to drug use during pregnancy.

• To reduce the high costs of ITNs;

• To increase the availability of safe drugs for use during pregnancy for malaria case

management.

Perspectives

Technical support will be strengthened to enable countries to implement effective

interventions for malaria prevention and control during pregnancy and to promote the

use of ITNs. Given the current limitations in human resources, the challenge during the

next two years will be to increase significantly the number of countries in which the

IPTp strategy is widely implemented. Also, the impact of malaria infection during

pregnancy in low transmission areas needs to be studied, and strategies to increase

ITN coverage needs to be incorporated within other programs and/or initiatives such

as immunization campaigns.


6

Malaria is the leading cause of morbidity and mortality in children under the age of fiveyears in the African Region. In most cases, early diagnosis and prompt treatment

would prevent progression to severe malaria and death.

Promoting Access to EffectiveTreatment

Three years after the Abuja Summit, many countries in the Region recorded

appreciable progress in pursuit of the Abuja targets. Several countries are increasing

the proportion of the at-risk population with prompt access to malaria treatment,

through interventions such as home management of fever. In 2003, products and

services planned for delivery included the following:

• Production and dissemination of guidelines on the use of combination therapy in the

African Region;

• Support countries to adopt and/or implement effective treatment policies;

• Support countries to operationalize combination therapy;

• Update Practical Handbook for Antimalarial Drug Therapeutic Efficacy Testing for the

District Health Worker;

• Support capacity strengthening in malaria case management and supervision;

• Produce and disseminate training materials and algorithms for case management.

Figure 1: The malaria algorithms are an easy-to-use tool for case management usingthe IMCI approach

7


Achievements

A rapidly increasing number of countries have reported intolerable levels of malaria-

parasite resistance to the commonly used antimalarial drugs, namely chloroquine and

sulfadoxine-pyrimethamine. This phenomenon has changed the approach to malaria

case management, based essentially on monotherapies for several decades. During

the past 12 months, with the support of the Regional Office, four countries

(Mozambique, Gabon, São Tomé Príncipe and Senegal) adopted combination

therapy for treatment of uncomplicated malaria.

• Severe pallor

• No pallor

• Some pallor

SEVERE ANAEMIA

NO ANAEMIA

ANAEMIA

• Give first dose of IV Quinine or suppositories of artemisinin or suppositories of artesunate

• Refer URGENTLY to the hospital

• Give mebendazole if child has not had a dose in the previous3 months

• Give advice on malaria prevention and use of ITN• In pregnant women, start IPT for malaria and give iron and

folic acid• Advice on when to return immediately

• Give first line oral antimalarial if high malaria risk• Give iron and folic acid• Give mebendazole if child has not had a dose in the previous

3 months• Give mother or patient advice on malaria prevention and use

of ITN• In pregnant women, start IPT for malaria and give iron and

folic acid• Advice on when to return immediately• Follow-up in 14 days

ClassifyANAEMIA


8

Countries used various processes in reaching consensus for adopting national

antimalarial drug policies. Senegal used the "classic approach" involving drug efficacy

studies, assessing provider and client views on current policy in public and private

sectors, piloting combination therapy in a few districts and, finally, holding a national

consensus meeting to review policy. Unique in the process leading to the national

consensus meeting was that 15 workshops involving target groups discussed the

results of the efficacy studies. The target groups were: the Medical Council;

associations of general practitioners, pediatricians, gynecologists, pharmacists,

paramedics, nurses; the Military Medical Services; trade unions; regional and district

medical officers; manufacturers and distributors of pharmaceutical products; private

practitioners; technical partners; funding agencies; and NGOs. The workshops

facilitated decision making at the national level, where the consensus meeting took

only two days to agree to change policy from chloroquine to combination therapy.

More countries are expected to make similar evidence-based decisions in the future.

In response to the need for countries to be oriented and guided on the selection and

use of combination therapy, after wide consultation, the Unit developed guidelines on

combination therapy for treatment of uncomplicated malaria.

The year also witnessed three countries implementing artemisinin-based combination

therapy treatment policies. Burundi and the island of Zanzibar (Tanzania) began

implementing amodiaquine plus artesunate treatment policy, and Zambia phased in

artemether-lumefantrine treatment in seven districts. The illustrative example of

Burundi follows.

The current configuration of treatment policies for uncomplicated malaria throughout the

African Region is presented in Figure 2.

Figure 2: Current treatment policies foruncomplicated malaria in the African Region(31 Dec 2003)

ACT PoliciesBurundi, Comores, Gabon, Ghana, São Tomé& Príncipe, South Africa, Zambia and ZanzibarIsland (Tanzania)

CT PoliciesEritrea, Ethiopia, Mozambique, Rwanda,Senegal, Uganda, Zimbabwe

SP PoliciesBotswana, DRC, Kenya, Malawi, Tanzania

CQ PoliciesAlgeria, Angola, Benin, Burkina Faso, CentralAfrican Republic, Cape Verde, Chad, Congo,Côte d’Ivoire, Equatorial Guinea, Guinea,Guinea-Bissau, Liberia, Madagascar, Mali,Mauritania, Namibia, Niger, Nigeria, SierraLeone, Swaziland Togo

ACT Policy = 8

CT Policy = 7

SP Policy = 5

CQ Policy = 22

EMRO Region


Burundi: The drug policy change process

Moving from Policy Decision to ImplementationIn 1983 Burundi recorded high resistance of Plasmodium falciparum to chloroquine

(55%) in health centres of Ninga and Bujumbura, and in 1992 resistance to SP (14%) at

Nyanza-Lac. In various sites in 2000/2001, treatment failure to chloroquine ranged

from 51.2% to 73.7% and to SP from 8.9% to 49.1%. In addition to the human cost,

Burundi estimated that in 1987 malaria cost the country US$730 million nationally and

US$117 per capita.

In response to the high levels of resistance, during a national consensus workshop in

July 2002, the Ministry of Health decided to withdraw chloroquine as a drug of choice

for treatment of uncomplicated malaria and to make SP the first-line treatment of

malaria during a transitional period while it sought to find a durable, alternative, long-

term drug policy for malaria.

Table 3 shows the results from ACT studies.

Comparisons of the efficacy of each combination, artemether-lumefantrine (99.3%) and

AQ / ASU (95.3%), show no statistically significant difference. They were equally

effective and well tolerated. No major adverse reactions were reported.

1. Based on the studies, the Ministry of Health changed the national drug policy to

AQ+ASU for treatment of uncomplicated malaria and for use in epidemic situations

and parenteral quinine for the treatment of severe malaria. To meet the costs of

procuring an estimated 12,150,000 tablets each for ASU and AQ for six months, the

Ministry requested financial assistance from its partners.

2. With input from the Malaria Unit, the MoH revised its training manuals in June 2003

to include the new protocols. The Unit also participated in training the trainers, and

WHO and UNICEF funded the training of health workers. The MoH with the support

of WHO and UNICEF developed a communication plan to inform the public about the

new protocol.

The MoH set up a technical committee in August 2003 to oversee implementation of

the new protocol and, in November, launched the new protocol officially once it had

obtained a stock of nearly 6 million tablets of AQ and ASU.

The sustainability of new protocols is supported by drug procurement from GFATM and

by the establishment of a regular monitoring system with assistance of a consultant

fielded for three months from the Malaria Unit. In addition, Burundi is being assisted to

set up a pharmaco-vigilance system.

ConclusionThe high-level political commitment of the national authorities, the effective and active

participation of development partners and organizations were key for the successful

implementation of the new drug policy in Burundi.

9


10

To strengthen AFRO’s capacity to provide technical support, 17 consultants were

briefed at a training workshop in Accra, Ghana, on drug policy formulation and

implementation. The consultants were from Anglophone, Francophone and Lusophone

countries and they are already providing technical support to countries.

Goal of Antimalarial Treatment Policy in Africa

From 14-15 August 2003, the Malaria Unit consulted with 16 experts from 13 countries

to examine the scientific evidence and advise the organization on whether the goal of

treatment policy needs to change from clinical cure to eradication of parasites. Data in

the literature and presentations from meeting participants were examined critically.

The meeting resolved that the current goal of antimalarial treatment policy is adequate,

with clinical cure and parasitological cure as primary and secondary objectives,

respectively. Based on available data, parasitological failure following treatment is

associated with increased risk of clinical episodes of malaria, anaemia and increased

gametocyte carriage. Noted further was that failing drugs often resulted in inadequate

clinical response and failed to clear parasites. It was agreed that endemic countries with

intense transmission should take into account rates of parasitological failure in addition

to rates of clinical failure in decision-making aimed at revising malaria treatment policy.

The key recommendation from the consultation was to set new cut-off points at which

malaria treatment policy should be updated. Countries should revise policy before

Adequate Clinical and Parasitological Response (ACPR) reaches below 75% and/or

Adequate Clinical Response (ACR) below 85%. The previous cut-off point was ACR

below 75%.

Table 3: Studies on antimalarial efficacy tests involving ACTs in Burundi

ACPR LTF ETF ETF+LTF

Products Sample % % % %

AQ+ASU 149 95.3 3.4 0.7 4.1

Artemether/ Lumefantrine 141 99.3 0.7 0.0 0.7

ACPR: Adequate Clinical and Parasitological Response LTF: Late Treatment FailureETF: Early Treatment Failure

11


Technical Support Networks for MonitoringAntimalarial Treatment

The Malaria Unit also strengthened the capacity of subregions to conduct surveillance

of antimalarial drug resistance by establishing technical networks for monitoring

antimalarial treatment. These networks are modeled on the lines of the East African

Network for Monitoring Antimalarial Treatment (EANMAT), which has been functional

since 1998. The goal of the networks is to contribute to a better understanding of the

epidemiology of antimalarial drug resistance in the subregions and to use the

information to develop appropriate treatment policies and improved case management.

In 2003, two new networks were established and two were supported to become

functional. The Central African Network for Monitoring Antimalarial Treatment

(CANMAT), whose membership includes Angola, Cameroon, Central African Republic,

Chad, Congo, Democratic Republic of Congo, Equatorial Guinea, and Gabon, was

launched in Kinshasa in May 2003. The first West African Network for Monitoring

Antimalarial Treatment (WANMAT I), consisting of Cape-Verde, The Gambia, Guinea,

Guinea-Bissau, Mauritania and Senegal, was launched in November 2003 in Dakar. The

second West African Network for Monitoring Antimalarial Treatment (WANMAT II) held

its first meeting in June 2003 in Ouagadougou. Its members are Benin, Burkina Faso,

Ghana, Mali, Niger, Nigeria, Sierra Leone, and Togo. SANMAT, comprising countries of

southern Africa, had its inception meeting in 2002 and will organize its second meeting

in 2004. The generic objectives of the networks are as follows:

• To detect, map and monitor the therapeutic efficacy of antimalarial drugs using

standardized tools and methods;

• To develop and maintain a database on the therapeutic efficacy of antimalarial;

• To share and disseminate information on the database with member countries of the

network and AFRO;

• To support the process and share experiences of antimalarial treatment policy

review in countries of the subregion;

• To advocate for effective and

efficient malaria treatment

policies in the subregion.

It is our vision that, in the long

run, subregions will adopt and

implement single treatment

policies, which will increase

local purchasing power and,

consequently, influence the

price of antimalarial drugs.

Figure 3 summarizes the

geographical distribution of the

networks.

Figure 3: Sub-regional technical supportnetworks for monitoring antimalarial treatment

WANMAT 1

WANMAT 2

CANMAT

SANMAT

EANMAT


12

In the area of malaria case management, 14 countries were supported to improve the

capacity of their health workers in malaria case management and supervision following

training (see Figure 4). Three of these countries also adapted new treatment guidelines.

Algorithms for malaria case management were developed (see Figure 5), field tested in

five countries and finalized for publication.

Eritrea Health Facility Survey

In 2002, Eritrea changed its national antimalarial drug policy to a combination of

chloroquine (CQ) and sulfadoxine-prymethamine (SP), as an interim solution before

adopting a WHO-recommended artemisinin-based combination therapy. This decision

necessitated change of national malaria treatment guidelines and re-training of front-

line health workers on case management. Training efforts have translated into

significant progress in the implementation of malaria control in Eritrea, particularly in

the area of IMCI and malaria case management.

To assess the quality of malaria case management in the light of recent drug policy shift

and the re-training of a large number of health workers, in November 2003, the Malaria

Unit conducted a health facility survey (HFS) in two administrative zones of Eritrea

called zobas: Debub and Gash Barka.

As Figure 4 demonstrates, most health facilities (70%) in both zones were observed to

have first and second line antimalarial drugs in stock on the day of the survey.

In addition, the survey results show that the vast majority of outpatients with suspected

malaria (about nine out of ten) were given or advised to take a combined treatment of

CQ and SP, according to national standards (Figure 5).

13


Hospitals HealthCenters

HealthStations

Clinics Overall

100

90

80

70

60

50

40

30

20

10

0

% o

f fac

ilitie

s

Facility type

CQ+SP Quinine Both

Figure 4: Availability of 1st and 2nd line antimalarial drugs in various healthfacilities of Debub and Gash Barka zones of Eritrea, November 2003

Hospitals HealthCenters

HealthStations

Clinics Overall

100

90

80

70

60

50

40

30

20

10

0

% o

f mal

aria

cas

es

Facility type

100

80

90

100

88

Figure 5: Percentage of suspected malaria cases that received CQ+SP on theday of the survey in Debub and Gash Barka health facilities, November 2003


14

The fourth Joint Malaria and IMCI Task Forces Meeting was held from 23 to 25

September 2003 in Harare, Zimbabwe. The 151 delegates focused on community-

based actions for prevention and control of childhood morbidity and mortality. The

meeting enabled countries and partners to share experiences on how to scale up

community-based interventions and further reinforced their partnership, advocacy and

resource mobilization efforts. The deliberations also enabled the gathering to make

concrete recommendations on how countries can make progress towards achieving

the Abuja targets and the Millennium Development Goals.

Challenges

• Problems related to availability, affordability and accessibility of ACTs, ranging from

quality assurance, negotiated prices etc.;

• Improving supply of efficacious antimalarial drugs in health facilities, including those

for the treatment of severe malaria;

• Lack of a tool to assist countries accurately estimate drug need for malaria

treatment;

• Assessment of the impact of case management training on quality or improvement

in care for malaria patients;

• Need for local production of ACTs within Africa.

Perspectives

In 2004, the Unit will focus on supporting countries to accelerate decision-making

process for treatment policy review, develop tools for estimating and forecasting needs

for ACTs at country level, advocate for harmonized subregional treatment policies and

assess the impact of case management training on treatment practices.

15


Praising community awareness and communication for behaviour change are key in promoting malaria control interventions

Community-Based Interventions

Community-based interventions (CBIs) are crucial for attaining the Abuja targets.

The different aspects of CBIs that are critical components of malaria control efforts

are home management of malaria (HMM), promotion of insecticide treated nets (ITNs),

indoor residual spraying (IRS) and intermittent preventive treatment (IPTp). The last

three are dealt with in detail elsewhere in this report.

The main problem in implementation of CBIs has been that the efforts have not been

coordinated. As a result, these efforts do not lead to anticipated outcomes. To address

this, the Malaria Unit proposed to conduct several technical support missions to identify

country-specific bottlenecks and, based on these, assist in addressing the challenges

of scaling up CBIs.

The main strategies to improve implementation of CBIs include raising community

awareness, building capacity, communication aimed at behavior change, advocacy,

social mobilization, establishment of partnerships for resource mobilization at all

levels, efforts to ensure the availability of malaria control products and services,

and monitoring and evaluation.


16

In 2003, supporting countries in scaling up community-based actions for malaria

control was a top priority, as was providing support for the establishment of technical

networks of individual and institutions involved in CBIs.

Achievements

During 2003, missions to countries provided technical guidance for scaling up

implementation of CBIs. The following guidelines were based on the outcomes of

two workshops on scaling up CBIs held in November 2002 in Lomé, Togo, for

Francophone countries, and in Harare, Zimbabwe, in December 2002 for Anglophone

countries:

• Guidelines for training community members on prevention of malaria and protection

during pregnancy;

• Guidelines for implementation and supervision of community-based interventions in

malaria control;

• Guidelines for community-based surveillance in malaria control aimed at tracking

morbidity and mortality events in the general population and mainly in children under

five and pregnant women.

In addition to these technical guidelines, a framework for developing national policy and

strategic plans to scale up implementation of CBIs was developed. Throughout 2003,

six countries were supported to complete the development of strategic and operational

plans for scaling up CBIs.

Technical support missions were also conducted at country level in Benin, Burkina

Faso, The Gambia, Ghana, Guinea-Bissau and Senegal, in collaboration with IMCI.

Three of these countries completed the development of a national policy and/or a

national strategic plan to scale up the implementation of CBIs: Benin, Senegal and

Guinea-Bissau. These countries also developed a national plan for communication

and social mobilization for malaria control. In addition, technical support was provided

to Benin for developing training modules for traditional practitioners.

Other countries that received orientation for development of national policy and national

strategic plans to scale up implementation of CBIs included Côte d’Ivoire, Ethiopia,

Guinea-Conakry, Liberia, Mali, Mauritania, Niger, Nigeria, and Mali. The 25 countries

implementing community-based interventions are: Angola, Benin, Burkina Faso, Congo,

Côte d’Ivoire, DRC, Eritrea, Ethiopia, The Gambia, Ghana, Guinea, Guinea-Bissau,

Kenya, Madagascar, Malawi, Mali, Mauritania, Niger, Nigeria, Senegal, Togo, Uganda,

Tanzania, Zambia and Zimbabwe.

In the area of HMM, the focus was on the empowerment of mothers and caretakers

with knowledge and skills about malaria management – to recognize its symptoms,

take immediate action at home, and to know when and where to seek help when

17


danger signs are present. Where feasible, communities were provided with

prepackaged drugs. The current evidence about implementation of HMM indicates

that the approach still is confined to a few project areas in countries.

In this year, at least 11 countries (Benin, Burkina Faso, Eritrea, Ethiopia, Ghana, Kenya,

Madagascar, Mali, Nigeria, Senegal and Uganda) had plans to scale up HMM from the

existing small-scale projects. The Malaria Unit provided technical support to some of

these countries for implementation of the strategy.

In scaling up, different models can be adapted depending on the specific country

experience. In Benin, for example, mothers were trained to give the right treatment

whenever there was suspicion of malaria/ fever. The unique feature of this model was

that the Malaria Control program planned the activities jointly with IMCI. As a result,

IMCI key practices were also addressed for the proper management of children with

fever and scaling up was much faster in the implementing areas. The major lesson

learnt was that building on existing programs helps achieve the required coverage

and better results.

Benin has also made several innovative interventions for HMM, training community

health workers in 1,335 Guinea worm-endemic districts to treat malaria in the home.

About 225 traditional healers were sensitized on the detection of danger signs in

support for HMM and 55,000 mothers were trained in managing malaria in under-

five-year olds. These innovative interventions provided a basis for implementing

activities to expand and scale up phases of HMM.

In Uganda however, the approach was to use an intermediate group to reach

mothers/caretakers. In this case, community resource people were trained and given

prepackaged antimalarial drugs for children presenting with fever. These prepacks

(HOMAPAKS) were color coded for the different age bands to allow mothers to

determine which pack to give to which child. In addition, resource people were

trained in counselling mothers on the IMCI key practices relating to the child with fever.

The program expanded to cover an additional 20 districts from the initial 10 of 2002.

In terms of geographical coverage, however, only five achieved 100% of all

communities implementing the strategy. For the remaining 15 districts, the range

was between 30-50%.

The ease of implementation was assessed in the districts implementing the strategy for

at least one year. The main objective was to review implementation and validate data

collected by the distributors to help other areas scaling up. As presented in Table 4,

the districts that were implementing had achieved high levels of appropriateness of

fever treatment. In almost all implementing districts, more than 90% of episodes

had been treated within 24 hours of onset of symptoms.


18

Table 4 shows that the correct treatment was given in more that 60% of cases with

fever, even when HOMAPAK was not available, unlike the below 40% in the control

group.

Other countries have also recorded major achievements. Madagascar, with the

assistance of Population Services International (PSI), launched prepackaged drugs

for private vendors under the brand name "Palustop". Efforts are underway to expand

distribution to cover most malaria-endemic areas. In Nigeria, the Society for Family

Health, working with the BASICS 2 project in collaboration with the Federal Ministry

of Health, launched the prepackaged antimalarial drugs in three states. This is

promoted under the brand name "KidCare".

Distributors of KidCare target drug vendors, from whom about 70% of mothers receive

treatment. Further support is expected from the Global Fund. Partners, including local

manufacturers, have helped get the product on the market.

Challenges

• Sustain commitment of countries for developing policies and strategic plans for

implementing and scaling up CBIs;

• Greater advocacy for more visibility of community-based malaria control

interventions at country level to spread awareness about the importance of CBIs;

• Scale up efforts (i.e., training community health workers) for CBIs to win support of

other partners, such as UNICEF and the Core Group, and collaboration of other

programs, such as IMCI, CSR/IDSR, Reproductive Health, Health Promotion and

Education;

• Ensure availability of malaria control commodities, e.g., efficacious antimalarial

drugs, ITNs and insecticides within communities;

Table 4: Levels of appropriateness of fever treatment in selected districtsin Uganda

Intervention districts Control districts

Chloroquine given for 62.1% 37.9%

3 days and once daily as

recommended

SP (Fansidar) given once 74.1% 25.9%

HOMAPAK given for 3 days and 67.6% HOMAPAK not being

once every day distributed

19


• Ensure capacity building for stronger IEC campaigns for behavior change;

• Better compliance efforts on use of prepackaged drugs;

• Improve drug regulatory and drug management structures for assuring drug quality

and management at all levels.

Perspectives

Priority in 2004 should be given to providing technical support to countries for scaling

up implementation of CBIs, and specifically HMM. Other priorities include promoting

prepackaging of antimalarial drugs for better compliance, providing evidence-based

guidance on the feasibility/acceptability of home management of malaria using ACTs,

advocacy and IEC efforts for CBI-related community education and behavioral change.


20

Indoor residual house-spraying remains the key intervention for epidemic prevention in areas of unstable malaria transmission

Epidemics Preparedness andResponse

Areas on the northern and southern fringes of the malaria-endemic belt of Africa, as

well as highland and desert areas, are at risk of epidemic malaria. Unlike in highly and

moderate endemic areas in Africa, malaria in epidemic-prone countries south of the

Sahara typically affects people of all ages and can have a high case fatality rate.

The Malaria Unit has been supporting efforts to improve the recognition and response

to malaria epidemics. Malaria early warning systems have been established in southern

Africa to improve outbreak detection and response and are being developed in other

parts of Africa prone to epidemics. Furthermore, preparedness plans of action

developed by 15 epidemic-prone countries constitute strengthened capacity

in EPR.

Achievements

In 2003, Malaria carried out many activities to support countries for malaria epidemic

control. Through the regional strategy for disease surveillance, many countries have

improved malaria surveillance system (43 countries are implementing this strategy in the

21


Region). Some countries (Mali, Madagascar, Niger, and Senegal) were supported in

setting up malaria epidemic early warning and detection systems. Sahelian countries

submitted a joint proposal for malaria epidemic control to the Global Fund with

Regional Office support. A training module on malaria epidemic control was tested

during courses in Benin, Ethiopia and Mozambique. Guidelines have been elaborated

to set up a country epidemic management committee and rapid response teams at

national and district levels.

On request, countries at risk of facing major malaria epidemics have been supported

(Burundi, Ethiopia, Madagascar, Mauritania, and Senegal). Contingency stocks have

been monitored and strengthened.


22

Most health systems in the African Region are confronted with challenges such as limited skilled and motivated human resources

and lack of support for logistics and operations. The problem is further compounded by frequent drug and supplies stock outs.

Capacity Development and Supportto National Health Systems

To ensure achievement of the long-term goal of locally sustainable malaria control

efforts, capacity development and the strengthening of health systems should be high

on the agenda of African governments and their partners. However, at all levels, the

number of trained malaria specialists is shrinking, from the specialized medical

entomologists and more general mid-level technicians to the community health worker.

The corps of expertise in health work must be strengthened throughout the African

Region and, in some disciplines, rebuilt entirely.

The shortage of human resources faced by health systems in Africa and limited support

to domestic training institutions are some of the major constraints in achieving the Abuja

targets, RBM and MDG goals. In 2003, priority in building up capacity in the Region

was given to: (1) strengthening malaria managerial skills and knowledge through

23


international courses on malaria control; (2) updating skills of malaria consultants; and

(3) linking Gates Malaria Partnership (GMP) and WHO/AFRO.

National malaria control programs have to struggle to maintain a critical presence within

changing and unstable health systems. The main concern is their ability to ensure that

malaria control is high on the national health agenda, mobilize health policy support and

develop strategies that can rapidly, effectively and equitably deliver access, coverage,

quality and impact with the available tools (diagnostics, drugs, ITNs, house spraying).

Capacity Development

Achievements

A review meeting of the international courses on Malaria and Planning its Control, held

14-16 April 2003 in Harare, Zimbabwe, recommended that international courses on

malaria be evaluated, the current curriculum reviewed, and a national curriculum for

malaria management for district level developed.

In 2003, three courses on Malaria and Planning Its Control were held at Nazareth

Training Centre, Ethiopia (for Anglophone countries), from 8 September to 29 November

2003; IRSP, Ouidah, Benin (for Francophone countries), from 1 September to

21 November 2003; and CRDS, Maputo, Mozambique (for Lusophone countries),

from 15 September to 5 December 2003. Eighty-one malaria program managers

and other health workers from 34 countries in the Region were trained.

To develop a pool of African consultants able to provide technical support to countries

and establish a network, a workshop for malaria consultants was jointly organized

with the Malaria Consortium, the Liverpool School of Tropical Medicine and the

London School of Hygiene and Tropical Medicine in Harare from 7-12 April 2003,

bringing together 17 experts from the public and private sector. The Malaria Unit,

in collaboration with Gates Malaria Training Centre in Blantyre, Malawi, conducted

training on malaria case management for focal persons in southern Africa.

In collaboration with the Tropical Diseases Research Centre (TDRC) in Ndola, Zambia,

15 participants from 14 countries attended a training of trainers course on malaria

laboratory diagnosis.


24

Many countries

have just begun

to appreciate

the importance

of continually

strengthening

capacity for malaria

control programs.

They realize that

human resource

and capacity building

should be assessed

and innovative training

methods introduced

to meet the countries’

demands and

needs.

Challenges

• Inadequacy of international courses on malaria curriculum to meet current needs;

• Lack of national curriculum for malaria program managers at district level;

• Insufficient follow-up and appropriate support to past trainees from international

courses on malaria;

• Lack of follow-up on malaria consultants;

• Insufficient knowledge on the human resource and institutional capacity needs at

country level;

• Poor and fragmented involvement of the domestic training institutions in support

capacity development at district level.

Perspectives

The focus for 2004 will be on: evaluation of international courses on malaria control

and review/develop the course curricula for international and national courses; follow up

of former trainees; assess human development and institutional capacity need; support

countries to develop appropriate human resource policies for malaria control; introduce

innovative approach for scaling up training; and involve domestic institutions in scaling

up capacity at district level.

The Minister of Health of Zambia (centre) at the laboratory training workshop, Ndola, Zambia, 2003

25


Support to National Health Systems

Achievements

The Malaria Unit provided robust technical support to countries to develop malaria

control strategic plans. Rwanda is one of the countries that were supported to develop

a national strategic plan for malaria control (see box). By the end of 2003, 35 of 43

malarious countries had completed their strategic plans and had begun scaling up

implementation of the control activities. Most of these countries now have work plans

for reaching the Abuja targets, RBM and Millennium Development Goals.

The Global Fund to fight AIDS, TB and Malaria (GFATM), formed in January 2002,

promises to provide additional funds to fight malaria. The Malaria Unit committed

considerable staff time and financial resources in supporting countries to develop

fundable proposals. During rounds one to three, 33 had their malaria proposals

approved for funding. US$327,850,815 was committed to the malaria programs in

these countries for a period of two years (Figure 6).

Figure 6: Global Fund support to fight malaria in the African Region

BeninNigerTogoChad

MadagascarLiberia

The GambiaRwanda

CameroonAngola

Democratic Republic of CongoSwaziland

ComoresMauritania

NamibiaBurkina Faso

EritreaGuineaGhana

SomaliaBurundi

Multi-Country Southern AfricaSudan (South)

MozambiqueSudan (North)

KenyaUgandaMalawiNigeria

EthiopiaTanzania (Zanzibar)

MadagascarMali

BeninSenegal

ZimbabweTanzania

Zambia

Firs

t R

ound

Sec

ond R

ound

Thir

d R

ound


26

Challenges

• Sustain the optimal amount of political, policy and program support from

governments and partners;

• Sustain the optimal level of investments and interest from the international

community in diseases of poverty;

• Limited funding;

• Difficulty having adequate human and financial resources to devote to malaria

control.

Perspectives

During the next 12 months, support to countries has been packaged according to

country needs for achieving the Abuja targets, RBM and MDG goals. Countries have

been grouped into three categories:

Category 1

Countries to be supported to develop district business plans for scaling up

implementation.

Category 2

Countries to finalize or review their malaria control strategic plans and to make

functional their in-country partnerships.

Category 3

Countries to be supported to develop malaria proposals for submission to the GFATM.

27


Strengthening monitoring and evaluation systems at country level is key to ensure that information collected is properly analyzed, shared and used for planning

and resource allocation

Monitoring and Evaluation

One of the challenges faced by malaria control programs in the African Region is the

availability of timely, complete and accurate data on malaria-associated morbidity and

mortality and on implementation and effectiveness of the control efforts. Monitoring and

evaluation data are not expected to provide all the information necessary for program

management by identifying the gaps and constraints that need to be addressed.

Nevertheless, these data are needed to demonstrate to policy makers, partners and

stakeholders that planned products are being efficiently delivered and that program

efforts are having measurable outcomes and leading to impact. They also help program

management by providing information on the practices that need to be promoted and

by providing insights as to where resources are being used most efficiently, versus

where new strategies should be considered. The overall goal of evaluation analysis is to

measure program effectiveness and impact.

Achievements

During 2003, capacity for monitoring and evaluating the implementation of malaria

control activities was strengthened in 14 countries (see map, Figure 7) through the

establishment of composite databases and the training of more than 100 health


28

workers and data managers/clerks from the NMCP, IDSR, HMIS, IMCI, EPI, the

university and research institutes in data management. The first edition of the

"Malaria Country Profiles", intended to be a useful tool in policy and decision-making,

was published.

Malaria Monitoring and EvaluationData Bases Established (14)

Data Bases yet to be established (29)

Non-AFRO countries

Figure 7: Status of malaria-related databases at country level as ofDecember 2003

At the level of the Regional Office, the EPI-INFO database developed previously was

converted into Access 2002 format for easy inclusion of components into the

integrated database of the DDC division under development. In addition, components

of community-based interventions made up of resource institutions/NGOs and projects

were developed and incorporated into the composite database (see sample menus,

Figure 8). Briefly, the composite database on malaria control interventions consists of:

• Routine malaria morbidity and mortality data;

• Community surveys;

• Health facility surveys;

• Management surveys;

• Monitoring of the implementation of planned activities and financial accountability;

• Regional core and supplementary indicators;

• Monitoring of antimalarial drug resistance and training of health personnel in malaria

control;

29


• Vector biology and control interventions;

• Community-based interventions; and

• Other information such as Roll Back Malaria Partnership, Operational Research on

Malaria Control and Malaria Epidemic Preparedness and Response.

Figure 8: Sample menus of the composite database in Access 2002

The pop-up menu of the composite databaselooks like this once you open the database:

A click on the "Go to Data Entry Menu" willopen the following pop-up menu:

Among the challenges related to the update/development of this database are inclusion

of data on the economic impact of malaria and development of a data warehouse

providing easy access to malaria data through the server and Internet.

Challenges

Problems related to the availability of appropriate human and financial resources make

it difficult for national malaria control programs to develop and sustain effective malaria-

related monitoring and evaluation systems. However, with the growing interest of

partners in malaria M&E and the new window of opportunity created by the GFATM

initiative, adequate resources for M&E are expected to increase soon. At AFRO level,

the strengthening of the M&E team made a significant impact on the support to

countries during 2003.

Perspectives

For many years to come, countries will continue to expect technical support from

AFRO in their efforts to develop comprehensive and efficient national M&E systems

for malaria control. Channels through which that support will be provided include

development and dissemination of appropriate guidelines for malaria M&E systems

and technical support missions.


30

Research on and development of new, effective antimalarial drugs are needed to replace failing treatment regimens

Operational Research

Throughout 2003, the Malaria Unit committed an enormous amount of staff time and

financial resources in supporting operational research at country level. It established

and maintained a database on operational research projects, organized a data analysis

workshop, supported the MIM/AFRO/TDR initiative, and provided technical support

mission to countries.

The program called "Strengthening Traditional Heath Systems for Malaria Control and

Prevention in the African Region" is a novel 5–year contributory project between WHO

and CIDA, which came into operation in November 2002. It supports improvement of

African traditional medicine practices and promotes research and production of safe,

effective and quality traditional medicines for malaria prevention and treatment.

Achievements

The gap between scientific knowledge and health policy and theoretical health

policy and practice is widening. Many public health tools and strategies with proven

laboratory or field trial efficacy do not realize tangible benefits in terms of disease

control. Unfortunately, research on translating results from field efficacy trials into field

31


effectiveness is lacking. Given this background, AFRO invests and supports capacity

strengthening for operational research to address problems identified during

implementation.

The products and services planned for delivery in 2003 are as follows:

• Operational research projects funded and implemented;

• WHO Collaborating Centres in malaria identified.

Furthermore, two research institutions have been identified for designation as WHO

Collaborating Centres. These are the Tropical Diseases Research Centre in Zambia

and the National Institute for Communicable Diseases in South Africa. Regional

databases on operational research, research institutions and staff have been

established and made accessible to countries and other users. Linkages with HQ

have been strengthened through creation of a new AFRO/RBM/TDR/MIM Research

Initiative, whose aim is to support operational research for malaria control. With initial

capital of $700,000, eight operational research projects from four countries have been

approved for funding under this initiative. In addition, 12 projects from 10 countries

received financial support and 12 projects funded in 2002 received supervisory visits.

A data-analysis workshop was held for 16 investigators from 14 countries whose

projects were funded in 2001. The workshop updated participants on data analysis

techniques, analyzed and interpreted findings from their studies and produced project

reports. Participants identified some constraints in the field, proposed solutions to the

constraints and made recommendations on future directions on how operational

research could be supported. Key recommendations included:

• Conduct supervisory visits to projects sites;

• Support the creation of a regional network on operational research in malaria;

• Convene a special workshop on computer skills for data-analysis for young

scientists;

• Continue to hold proposal development workshops for operational research in

malaria until a critical mass of trained manpower is achieved;

• Identify and support mechanisms for enhancing capacity to link research,

implementation and control.

During the past 12 months, traditional medicines were researched for their potential

role in the fight against malaria. With support from WHO-HQ and CIDA, linkages were

established with institutions and country programs for quality research on potential

traditional medicines for malaria treatment and prevention. The Ministry of Health in

Mozambique together with experts from the University Eduardo Mondlane of Maputo

were supported to carry out comparative trials of herbal tea from Artemissia annua

versus SP to treat malaria. The Tropical Diseases Research Centre in Ndola, Zambia,

is performing clinical evaluations for preliminary efficacy and safety profiles of an herbal

concoction called Mbosha for treatment of uncomplicated malaria. In the area of


32

malaria prevention, the Malaria Unit is working with the International Centre for Insect

Physiology and Ecology (ICIPE) to evaluate the effectiveness of a mosquito-repellent

plant called Ocimum kilimandscharichum when used as a traditional fumigant in

villages.

In addition, the Malaria Unit supported the Ugandan Ministry of Health and the National

Malaria Control Program to harness community resources. The program used traditional

health practitioners and traditional birth attendants in two rural districts to deliver IPTp

within a minimum package context of IEC materials and SP. This strategy is intended to

capture the largest number of pregnant women possible and provide them with

appropriate advice for antenatal care at the nearest health facility at least four times

during pregnancy.

Challenges

By promoting the role of science and operational research in decision making,

countries and their national and international partners have sought to assist health

care decision makers and policy makers in managing malaria control activities.

The concern here is that guidance from operational research is irrelevant to the

millions of people who live in communities where health systems are breaking down

and where access to effective treatment and/or preventive tools is limited.

This is a new area for operational research, and some potential partners and countries

show some hesitation. There is a significant, and probably justified, fear of loosing

intellectual property rights (IPR) and traditional medicine knowledge. This fear has

often created distrust about transparency between traditional healers and scientists.

Strong popular advocacy and institutionalization of legislation and guidelines for IPR

would help minimize this concern.

Member Countries are generally supportive and display tremendous will to have

traditional medicines promoted and evaluated. They are concerned about the lack

of guarantee of continuing financial support from partners.

Perspectives

In Africa, the potential impact of traditional medicine practice is poorly understood and

appreciated. The attempt to couple traditional and conventional medicine practice on

a common platform of evidence-based practice is the most plausible strategy for

the future.

33


Economics of Malaria

During 2003, the Malaria Unit set out to obtain evidence of the economic burden of

malaria on countries in the Region. At the end of the year, there was a better

understanding of the economic burden of malaria.

Financing malaria control activities remains a critical challenge. Efforts to maintain

routine program activities and ambitions to scale up coverage of the major interventions

have been hampered by financial constraints. For some countries, however, the period

under review was marked by significant expansion of the fiscal space, primarily from

new resources linked to debt relief, grants from the Global Fund (described elsewhere

in this report) and commitments from donors through sector-wide approaches (SWAp)

and budget support.

Achievements

Studies to assess the economic burden of malaria were completed in Ghana and

Chad during the year. A study is partially completed in Nigeria, and one was

commissioned in Mali and Uganda in the latter part of the year. Results from the

completed studies have confirmed that as a single disease, malaria significantly

inhibits economic growth. The evolving evidence from preliminary results obtained in

three countries confirm that malaria impedes economic growth in African countries,


34

ranging from 0.41% in Ghana to as high as 3.8% in Nigeria and 8.9% from Chad.

These results will provide significant impetus to national advocacy efforts in giving

malaria the due attention of policy makers and those in charge of allocation of

resources to ministries of health.

Most of the costs of preventing and treating malaria in Africa today are borne by the

people themselves. For example, people buy nets, insecticide sprays and coils, and

people spend a considerable amount of money and time on malaria treatment. Data

from recent studies are revealing a pattern of immense burden, particularly for the

poorest households. In Ghana, for example, the direct cost of treating malaria to the

household is US$6.87 for each single episode of malaria. Although this amount is

well beyond the capacity of most households in Ghana, when the indirect costs were

computed, the cost of malaria treatment comes to an even higher figure of US$8.92.

Throughout the year, Regional Office has investigated financial and non-financial barriers

to scaling up malaria control in the Region. Using Ghana as a pilot, the Regional Office

worked in collaboration with staff of the World Bank and RBM Secretariat to review the

financing of malaria at the district level. Their findings have been used to identify

obstacles and gaps and recommendations for overcoming them. This initiative,

conducted in the context of the SWAp arrangement in place in Ghana, provides a

good starting point for providing similar support to countries with decentralized

systems or those implementing SWAp.

Over the years, several countries, such as Burkina Faso, Cameroon, Malawi, Mali,

Mauritania, Mozambique and Tanzania, have increased their health budgets significantly,

expanding the capacity of the health sector to finance more easily their recurrent health

costs. Specifically, the government of Cameroon made significant allocations to malaria

control from its debt relief support under the Highly Indebted Poor Countries (HIPC)

initiative. During the period under review, about 450,000 ITNs were procured for free

distribution to pregnant women.

Challenges

• Expanding the resource envelope for malaria control activities, particularly taking

advantage of in-country sources such as HIPC;

• Fostering collaboration with country partners, while strengthening the capacity of

national programs for resource mobilization and negotiations;

• Raising the level of commitment of teams participating in studies on the economic

burden of malaria; and

• Increasing the capacity of national programs and WHO Country Offices in health

economics.

35


Perspectives

Countries will continue to expect technical support from AFRO for understanding the

economic ramifications of malaria. AFRO will build the capacity of national programs

on costing of interventions. More specifically, AFRO will support countries that have

adopted new drug policies for costing the implications of the change. Support will

also be provided to national programs to enable them to engage in ongoing health

sector reforms and sector wide approaches.


36

Partnerships Development

During the period under review, the Malaria Unit worked closely with its traditional

partners and embraced new partners to join in the fight against malaria. As a key

partner in the Global RBM Partnership, and the base for the Partnership Secretariat

in the Region, the Unit hosted the third RBM board meeting in Harare in September.

In February, the Unit hosted a meeting of African representatives on the Partnership

Board with members of their constituencies. The Unit facilitated African representatives

to represent the Region on the RBM Partnership Board and countries to nominate

RBM focal people at country level for partnership building and improving consultations,

communications and information sharing. So far, 18 countries have nominated RBM

focal people. The Unit participated in several activities of the board – meetings,

teleconferences, etc.

At the technical level, the Malaria Unit provided input into deliberations of RBM

Partnership on key developments during the year. Specific meetings on access to

and financing of ACTs, monitoring and evaluation of RBM, malaria in pregnancy, etc.

hosted by different RBM partners and Working Groups received substantial inputs

from the Malaria Unit.

The Joint Malaria and IMCI Task Forces meeting, which brings together countries,

partners, researchers and WHO, was held during the year (reported earlier in

this report).

37


DFID, USAID, and the World Bank remained the principal financial partners of the Unit.

With funds from these partners, the Malaria Unit was able to strengthen its human

capacity at regional, intercountry and country levels and extend its technical support

in quality and quantity. Working with its Malaria Action Coalition (MAC) partners, the

Unit provided technical support to several countries during the year, particularly in the

area of drug policy change and malaria prevention and control during pregnancy.

With support provided by CIDA, the Unit was able to extend it support to countries

for strengthening their traditional health systems for malaria control, with Mozambique,

Kenya, Tanzania, Uganda and Zambia benefiting from direct technical support in

this area.

The celebration of Africa Malaria Day 2003 in Kenya demonstrated the strengthened

partnership built by the Unit. The highest level government representatives and principal

officers of the major RBM partner agencies participated in the event. At the occasion,

the first Africa Malaria Report was launched. This high-level focus on malaria on the

day was replicated in malaria-endemic countries across the Region, with the

participation of a wide range of in-country partners, including the private sector.

In some countries, the Malaria Unit fielded consultants to provide support for

planning the Day. The Unit provided advocacy and campaign materials to all countries.

On Africa Malaria Day, a special site was opened on the Unit’s web page, a special

edition of the Malaria Bulletin was published and countries of the Region held events

marking the day, which were described in the first Africa Malaria Day Report ever

published.


38

Program Management

The Malaria Unit’s role in the battle against malaria within the context of Roll Back

Malaria is to guide countries and partners to scale up massively the agreed upon

malaria control strategies and policy orientations. While this requires an increased

presence in countries for designing and implementing these strategies, the current

staffing levels of the Unit have the capacity to meet the malaria control needs of the

Member States. An attempt was made to match staff profiles with changing needs,

and by year-end 2003, 92 malaria staff were employed within a three-tiered structure:

24 staff at Regional Office (including other units), 21 in intercountry teams and 47

Malaria Program Officers in the Country Offices.

Regional Level

The Unit acts as a center in the major malaria intervention areas, linking and

coordinating with relevant units, ensuring that technical standard guidelines and

agreed strategies for malaria control are updated regularly and disseminated to

countries and partners. The Unit is also responsible for providing a level of technical

Effective Treatment

Drug Policy /Team CoordinatorDr T. Sukwa (MDP)

Home-basedManagement

Dr J. Namboze (MHM)

Case ManagementDr I. Sanou (MCM)

Community-basedInterventions

Dr T. Diarra (MCI)

Traditional Systemsfor Malaria

Dr A. Oloo (MTS)

Monitoring andEvaluation

Monitoring andEvaluation /

Team CoordinatorDr A. Alisalad (MMO)

Monitoring andEvaluation

Dr J. Uchudi (MEO)

Malaria Prevention

Prevention Officer /Team CoordinatorDr A. Ba (MPO)

Technical OfficerMr G. Baugh (MTO)

Administrative OfficerMr E. Kagoro (MAO)

RBM Partnership Focal PersonDr E. Afari (MRP)

Regional Malaria Control Advisor

Dr Magda Robalo (MAL)

Support Team

Support TeamCoordinator

Mr R. Agyarko (MSS)

Health SystemsDr K. Kamanga (MHS)

CommunicationMs M. Lengor (MCA)

Economics andFinancing

Dr T. Okorosobo (MEF)

Capacity DevelopmentDr F. Silveira (MCD)

Capacity DevelopmentDr A. Davies (MGP)

Operations ResearchDr E. Kamau (MOR)

IntercountryPrograms

ICP CoordinatorDr S. Fall (MIC)

ICP West AfricaDr S. Tohon

ICP East AfricaDr S. Paluku

ICP Central AfricaDr C. Ngabonziza

ICP Southern AfricaDr S. Murugasampillay

Malaria Control Unit, WHO Regional Office for Africa, December 2003

39


support that is consistent with countries’ demands and needs. Five teams provide

clarity of vision in the key technical areas and approaches.

Intercountry Level

The intercountry teams constitute a solid, decentralized and reliable structure for

providing technical support to operationalize priority areas of the malaria control

program. After the Country Office, the intercountry teams provide the second level

of communication of procurement of technical and managerial support in the

context of country planning and management on a periodic basis.

Country Level

The primary responsibility of the WHO Country Office (WCO) is to ensure that national

authorities and their partners are able to carry out cost-effective malaria control

measures as part of developing health systems. To meet the challenge of sufficient

coverage, national and district implementation plans must be developed with key,

time-bound targets and adequate financing.

In 33 of 43 malaria-endemic countries, the WHO Country Office provides a Malaria

National Program Officer (NPO) and in some cases an International Program Officer

Figure 9: AFRO epidemiological blocs

Non-AFRO

West Africa

Central Africa

East and Great Lakes

Southern Africa

Lomé

LibrevilleKampala

Harare


40

(IPO) to support the WHO Country Office to maximize effectiveness in its advisory role.

The NPO or IPO works specifically with the Ministry of Health to focus on malaria

control activities for setting priorities, planning and budgeting, especially at the district,

community and household levels. The NPOs and IPOs provide day-to-day support

ranging from technical to strategic and tactical.

The WHO Country Office also acts as the first level of communication for procurement

of technical support, accessing resources from the ICP teams, Regional Office, HQ

and partners.

An annual review and planning meeting at intercountry level facilitates coordination

between regional, intercountry and country levels, providing a forum for interaction

with countries, partners and staff involved in implementation (see Table 5). Beginning

in December 2003, every two years, the NPOs and IPOs are invited to the regional

review and planning meeting.

Table 5: Areas of coordination/collaboration with other programs

IMCIIntegrated Management of

Childhood Illness

EPIExpanded Program on

Immunization

CSR, VBC and CRDCommunicable Disease

Surveillance and ResponseVector and Biological Control Communicable Disease

Research and Development

MPSMaking Pregnancy Safer

Program

The strategy for the Integrated Management ofChildhood Illness (IMCI) has been incorporated intomalaria control interventions for uncomplicated casemanagement. Close collaboration with IMCI is activeand will be further expanded as IMCI expands itsactivities at the country level.

Approaches for collaboration with EPI duringimmunization campaigns to deliver ITNs are beingexplored. The promising IPTp strategy calls for aclose collaboration with EPI. Of utmost importance is the collaboration with EPI in surveillance andmonitoring, building on the experience of the polioteam.

Within the spirit of integration being implementedacross DDC, some malaria control interventions -promotion of ITNs, epidemic preparedness andresponse and operational research - are implementedby other units/areas of work. It is expected that close collaboration, joint planning, implementation,monitoring and evaluation will be conducted toachieve the malaria control-related objectives.

Pregnant women are the second most importantvulnerable group to malaria, after children under the age of five years. Malaria in pregnancy is animportant cause of anemia and low-birth weight.Collaboration with the Making Pregnancy SaferProgram (MPS) is of utmost importance for ensuringthat malaria control policies concerning pregnantwomen are in line with WHO recommendations.Collaboration with MPS is ongoing, and the MalariaUnit is developing a framework streamlining suchcollaboration from country to regional levels.

41


Issues Associated withImplementation of the 2003 Work Plans

The third Malaria annual review and planning meeting was held in Johannesburg,

South Africa, from 1 to 5 December 2003. WHO staff from HQ, regional, intercountry

and country offices as well as some partners involved in malaria control work in the

Region attended the meeting.

Through the presentations and deliberations, the meeting provided a forum for

identifying ways to enhance the quality of support provided to countries and to

strengthen coordination in the implementation of malaria control activities.

Overall, it was observed that appreciable progress was made at all levels in the

implementation of the 2003 work plans. Issues identified during the meeting as

associated with implementation of the 2003 work plans include the following:

West and Central Africa

• Currently, the countries of the subregions are using ITNs only for vector control,

although AFRO is supporting countries to promote and develop IVM programs;

• With sentinel surveillance going on in different sites for drug efficacy and vector

resistance, it was suggested that countries consider using the same sentinel sites

for both activities;

• Data on implementation of activities and coverage of interventions were available in

some countries, but not in others. Also, there are concerns about the methods and

sources of data reported from countries, suggesting that the systems for collecting

and reporting data need to be strengthened;

• The emergence of several networks and multiple partners could put a strain on

NMCPs and NPOs, not allowing enough time for program activities;

• The need to strengthen the collaboration between Malaria and IMCI at country

and subregional levels.

East and Great Lakes and Southern Africa (including Madagascar)

• Epidemiological blocs need to collect systematically and present trend data on

indicators for all countries, capturing not only the effects of control efforts made

by WHO but also those of other partners;

• Coordination of supports provided by WHO and its partners needs to be improved

to minimize disruptions in the smooth implementation of country and ICP work

plans. Mutual respect, listening to what countries want and planning together

were identified as key prerequisites for good working relationships between

countries, country offices and ICP teams;

• Concerns over the cost of malaria commodities (such as ITNs and ACTs) and

delays in procurement pose serious challenges to countries and particularly

the poor, despite increased funding for malaria control activities;

Regional Level

• The need to initiate/strengthen collaboration with NGOs in countries;

• The way WHO should operate in countries with highly decentralized governance

systems, such as Nigeria;

• Provision of guidance for NMCPs and NPOs on how to engage in the activities of

subregional networks, which are responsible for follow up in the countries.

Epidemiological blocs compiled and summarized information on how countries were

progressing and the gaps remaining for scaling up implementation of interventions to

achieve the Abuja targets. Some of the gaps and challenges identified were:

• The high cost of commodities (ACTs and ITNs), and their current inadequate

supplies;

• Inadequate capacity for quantification and forecasting commodity needs

(drugs, nets and insecticides for net treatment);

• Shortage of trained human resources for effective case management;

• Inappropriate treatment-seeking behavior due to low sensitization of

communities;

• Risk of Global Fund resources eclipsing efforts to increase government funding

for malaria;

• Low capacity of health systems to absorb increased resources for malaria

control;

• Inadequate capacity of NMCPs to mobilize and coordinate partners.


42

43


Conclusion

During 2003, the Malaria Unit strengthened the existing capacity of malaria prevention

and control programs in various ways in several malaria-endemic African countries.

It provided substantial support to national efforts to adopt appropriate antimalarial drug

policies, to develop strategies for increasing access to malaria control interventions,

at all levels of the health system and particularly at the community level, and to

strengthen the national capacity for epidemic detection and response in epidemic-

prone countries. Overall, the national capacity of many countries for planning,

management, implementation, monitoring and evaluation, operational research,

partnership building, advocacy and resource mobilization was strengthened.

The critical challenge for malaria control in the Region is to expand coverage of

various interventions to levels that will achieve the Abuja targets, RBM and MDG

goals. Scaling up control interventions has been hampered by limited human

resources, particularly at implementation level and inadequate skills mix; the slow

pace of drug policy review and incorporation of new approaches (e.g. intermittent

preventive treatment during pregnancy); inadequate funding for development of

health systems and service delivery (e.g. logistics, supervision); high costs of malaria

commodities (nets, drugs, insecticides, etc); insufficient linkages with other government

sectors (e.g. Ministry of Finance) and initiatives (e.g. Highly Indebted Poor Countries);

limited decentralization to districts (operational level); and, poor coordination of

partners’ action at country level.

Throughout the next 12 months, WHO/AFRO will undertake concerted actions with

countries and partners to increase access of at-risk groups to quality, cost-effective

interventions. The capacity of countries to implement a comprehensive package of

malaria control interventions will be strengthened. Working with partners, WHO/AFRO

will support countries to scale up the use of insecticide treated nets and other vector

control measures such as indoor residual spraying in selected areas as appropriate;

to increase the proportion of pregnant women accessing intermittent preventive

treatment and improve access to prompt and effective treatment; and to strengthen

traditional health systems for malaria prevention and treatment. Particular attention will

be given to operational research for development of new tools and improvement of

existing ones; malaria epidemic prevention and control; and to strengthen malaria

surveillance and mechanisms for monitoring and evaluating the control efforts.


44

M A L A R I A U N I TD I V I S I O N O F P R E V E N T I O N A N D C O N T R O L O F C O M M U N I C A B L E D I S E A S E S

R E G I O N A L O F F I C E F O R A F R I C A • W O R L D H E A LT H O R G A N I Z AT I O N

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